Capnography can be used to summarize 3 key applications for intubated patients: 1) It can confirm correct endotracheal tube placement and detect displacement. Characteristic waveforms indicate proper vs displaced placement. 2) During CPR, it can assess the effectiveness of chest compressions by correlating end-tidal CO2 levels with cardiac output and blood flow. 3) It provides an early indicator of return of spontaneous circulation through a rapid rise in CO2 levels, earlier than other signs like pulse or blood pressure. It also aids the decision to cease resuscitation efforts based on CO2 levels.

1. CAPNOGRAPHY In Emergency Care EDUCATIONAL SERIES Part 3: Intubated

2. Part 3: The Intubated Patient CAPNOGRAPHY In Emergency Care

3. Part 3: The Intubated Patient Learning Objectives List three intubated applications Identify four characteristic patterns seen in: Correct ET tube placement ET tube displacement Effective chest compression ROSC

4. The Intubated Patient

5. Capnography Applications on Intubated Patients Confirm correct placement of ET tube Detect changes in ET tube position immediately Resuscitation Assess adequacy of chest compressions Detect ROSC Objective data for decision to cease resuscitation Optimize ventilation of patients Document, document, document

6. Confirm ET Tube Placement Traditional methods of confirmation Listen for breath sounds Observe chest movement Auscultate stomach Note ET tube clouding These methods are subjective and unreliable

7. Confirm ET Tube Placement “ Standard physical examination methods, such as auscultation of lungs and epigastrium, visualization of chest movement, and fogging in the tube, are not sufficiently reliable to exclude esophageal intubation in all situations.” Source: Verification of Endotracheal Tube Placement - Approved by the ACEP Board of Directors, October 2001 h t tp ://www.acep.org/1,4923,0.html (policy statement)

8. Confirm ET Tube Placement “… emergency responders must confirm tracheal tube position by using nonphysical examination techniques.” P I-87 Secondary confirmation with an EtCO 2 or esophageal detection is Class IIa recommendation P I-150 Source: Guidelines 2000 for Cardiovascular Resuscitation and Emergency Cardiovascular Care, Circulation 102 (suppl I) 8. August 22,2000

9. Confirm ET Tube Placement “… end-tidal CO 2 monitors can confirm successful tracheal tube placement within seconds of an intubation attempt” P I-101 “ The presence of exhaled CO 2 indicates proper tracheal tube placement.” P I-101 Source: Guidelines 2000 for Cardiovascular Resuscitation and Emergency Cardiovascular Care, Circulation 102 (suppl I) 8. August 22,2000

10. Confirm ET Tube Placement “… devices that use capnographic waveforms are so sensitive that the devices can detect residual CO 2 (during CA) when the tube is in the trachea”. P I-383 Source: Guidelines 2000 for Cardiovascular Resuscitation and Emergency Cardiovascular Care, Circulation 102 (suppl I) 8. August 22,2000

11. Confirm ET Tube Placement 108 patients intubated in the field 52 trauma patients 56 medical patients ET tube placement checked on arrival at the ED 27 patients (25%) had improperly placed ET tube 18 were in the esophagus 9 in oropharynx with tip above the cords Source: Falk J., Sayre M.R. 1999. Confirmation of Airway Placement, Prehospital Emergency Care 3: 273-278

12. Confirm ET Tube Placement “ Consensus was reached that EtCO 2 evaluation was currently the best method for confirming correct endotracheal tube placement. The group agreed that quantitative capnography was currently the best method for determining endotracheal tube position and strongly recommends its use.” P 295 Turtle Creek Consensus Conference on Prehospital Care Source: Wayne M., et al. 1999. Management of Difficult Airways in the Field, Journal of Emergency Medicine 3: 290-296

13. Confirm ET Tube Placement “ All endotracheal intubations must be accompanied by an objective confirmation… The optimal method of measurement is quantitative capnography and its use on all intubated patients.” P 277 Source: Falk J., Sayre M.R. 1999. Confirmation of Airway Placement, Prehospital Emergency Care 3: 273-278

14. Confirm ET Tube Placement 108 patients intubated in the field Compared to the Falk study 9% had improperly placed ET tube versus 25% in previous study No unrecognized misplaced ET tubes in patients with continuous end-tidal CO 2 monitoring Source: Silvestri S. J., et al. 2003. Improvement in Misplaced Endotracheal Tube Recognition within a Regional Emergency Medical Services System, Academic Emergency Medicine 10 (5): 445 (Abstract)

15. Confirm ET Tube Placement Capnography provides Objective confirmation of correct tube placement Documentation of correct placement

16. Confirm ET Tube Placement 4 5 0

17. Confirm ET Tube Placement ET tube placement in esophagus may briefly detect CO 2 Following carbonated beverage ingestion When gastric distention was produced by mouth to mouth ventilation Residual CO 2 will be washed out after 6 positive pressure breaths

18. Detect ET Tube Displacement A properly placed ET tube can be displaced out of the trachea without any movement of the proximal tip Source: Matera P. 1998. The Truth About ET Tube Movement, JEMS 23: 34-42

19. Detect ET Tube Displacement “…risk from a misplaced tube is unacceptably high and clinical signs confirming tube placement are not completely reliable” P I-296 “…animal data shows that detection of a displaced or obstructed tube using pulse oximetry or changes in heart rate or blood pressure may be delayed more than 3 minutes” P I-296 Source: Guidelines 2000 for Cardiovascular Resuscitation and Emergency Cardiovascular Care, Circulation 102 (suppl I) 8. August 22,2000

20. Detect ET Tube Displacement “… use of a device to confirm tracheal tube placement in the field, in the transport vehicle, and on arrival to the hospital is desirable and strongly encouraged.” P I-296 “ Use of a device to confirm tube placement on arrival at the hospital is especially important because displacement of the tube is most likely to occur when the patient is moved into and out of the transport vehicle.” P I-296 Source: Guidelines 2000 for Cardiovascular Resuscitation and Emergency Cardiovascular Care, Circulation 102 (suppl I) 8. August 22,2000

21. Detect ET Tube Displacement “ Continuous capnography detects acute airway obstruction and hypopharyngeal extubation more rapidly than does pulse oximetry or vital sign monitoring in a hyperoxemic porcine model.” Source: Poirier M. P., et al . 1998. Utility of monitoring capnography, pulse oximetry, and vital signs in the detection of airway mishaps: A hyperoxemic animal model, Am J Emerg Med 16: 350-352.

22. Detect ET Tube Displacement “ … displacement of the tube is most likely to occur when the patient is moved into and out of the transport vehicle.” P I-296 Source: Guidelines 2000 for Cardiovascular Resuscitation and Emergency Cardiovascular Care, Circulation 102 (suppl I) 8. August 22,2000

23. Detect ET Tube Displacement Traditional methods of monitoring tube position Periodic auscultation of breath sounds Gastric distention Worsening of patient’s color Late sign of tube displacement These methods are subjective and unreliable —and delayed

24. Detect ET Tube Displacement “ Continuous capnography monitoring devices can identify and signal a fall in exhaled CO 2 consistent with tracheal tube dislodgement. This may be very helpful in emergencies when clinicians have other responsibilities.” P 140 Source: ACLS-The Reference Textbook, ACLS: Principles and Practice. Ed. 2003 Cummins, R.O. American Heart Association. ISBN 0- 87493-341- 2

25. Detect ET Tube Displacement Capnography Immediately detects ET tube displacement Source: Murray I. P. et. al . 1983. Early detection of endotracheal tube accidents by monitoring CO 2 concentration in respiratory gas. Anesthesiology 344-346 4 5 0 Hypopharyngeal Dislodgement

26. Detect ET Tube Displacement Only capnography provides Continuous numerical value of EtCO 2 with apnea alarm after 30 seconds Continuous graphic waveform for immediate visual recognition Source: Linko K. et. al . 1983. Capnography for detection of accidental oesophageal intubation. Acta Anesthesiol Scand 27: 199-202 4 5 0 Esophageal Dislodgement

27. Confirm ET Tube Placement Capnography provides Documentation of correct placement Ongoing documentation over time through the trending printout Documentation of correct position at ED arrival

28. Capnography in Cardiopulmonary Resuscitation Assess chest compressions Early detection of ROSC Objective data for decision to cease resuscitation

29. CPR: Assess Chest Compressions Properly done chest compressions provide 25-30% of normal blood supply to the brain 5%-10% of normal blood supply to the heart Adequate chest compressions promote the elimination of metabolic wastes

30. CPR: Assess Chest Compressions Airway - open with ET tube Breathing - controlled and stable Circulation - cardiac output directly related to changes in EtCO 2 Capnography provides noninvasive method for monitoring blood flow generated by chest compressions

31. CPR: Assess Chest Compressions 19 minipigs Relationship between EtCO 2 and cardiac output Measured before cardiac arrest and during CPR Source: Weil M. H. 1985 . Cardiac Output and end-tidal carbon dioxide, Critical Care Medicine 13 (11): 907-909

32. CPR: Assess Chest Compressions Good correlation between EtCO 2 and cardiac output Decrease in EtCO 2 reflects a critical reduction of cardiac output Low cardiac output Reduces blood flow to the lungs Fails to clear CO 2 from the bloodstream Source: Weil MH. 1985. Cardiac output and end-tidal carbon dioxide, Critical Care Medicine 13 (11): 907-909

33. CPR: Assess Chest Compressions Under conditions of constant ventilation, capnography correlates with the circulatory status produced by chest compressions EtCO 2 has potential value in monitoring effectiveness of CPR Source: Weil MH. 1985. Cardiac output and end-tidal carbon dioxide, Critical Care Medicine 13 (11): 907-909

34. CPR: Assess Chest Compressions Rescuer fatigue Ochoa Study Rescuers were not able to maintain adequate chest compressions for more than 1 minute Rescuers did not perceive fatigue even when it was measurably present Source: Ochoa, F. Javier, et al. 1998. The Effect of Rescuer Fatigue on the Quality of Chest Compressions, Resuscitation April; 37: 149-52

35. CPR: Assess Chest Compressions Increase in EtCO 2 has been shown to correlate with A fresh rescuer at a faster compression rate A new rescuer during CPR with no change in rate Mechanical compressions Source: White R. D. 1994. Out-of-Hospital Monitoring of End-Tidal Carbon Dioxide Pressure During CPR, Annals of Emergency Medicine 23 (1): 756-761

36. CPR: Assess Chest Compressions “ …measurement of end-tidal carbon dioxide concentration may be a practical, noninvasive method for monitoring blood flow generated by compression during cardiopulmonary resuscitation and an almost immediate indicator of successful resuscitation.” Source: Falk J. L. 1988. End-tidal carbon dioxide concentration during cardiopulmonary resuscitation, New England Journal of Medicine 318 (10): 607-611

37. CPR: Assess Chest Compressions Use feedback from EtCO 2 to depth/rate/ force of chest compressions during CPR 4 5 0

38. CPR: Detect ROSC 90 prehospital patients intubated in the field 16 survivors In 13 survivors a rapid rise on CO 2 production was the earliest indicator of ROSC Before a palpable pulse Prior to blood pressure Source: Wayne M.A. 1995. Use of End-tidal Carbon Dioxide to Predict Outcome in Prehospital Cardiac Arrest. Annals of Emergency Medicine 25 (6): 762-767

39. CPR: Detect ROSC 10 patients on ventilators in ICU EtCO 2 increased within 30 seconds of ROSC in 7 Rapid rise on CO 2 production was earliest indicator of ROSC “…an abrupt increase in the EtCO 2 under conditions of reasonably constant ventilation provides the earliest evidence of successful resuscitation.” Source: Falk J. L. 1988. End-tidal carbon dioxide concentration during cardiopulmonary resuscitation, New England Journal of Medicine 318 (10): 607-611125

40. CPR: Detect ROSC Sudden rise in EtCO 2 Confirm with ECG and capnography Questionable pulse Arterial vasoconstriction may make pulse difficult to detect

41. CPR: Detect ROSC Briefly stop CPR and check for organized rhythm on ECG monitor 4 5 0

42. Decision to Cease Resuscitation Capnography Has been shown to predict probability of outcome following resuscitation May be used in the decision to cease resuscitation efforts Source: Levine R. L. 1997. End-tidal carbon dioxide and outcome of out-of-hospital cardiac arrest. New England Journal of Medicine 337 (5): 301-306 .

43. Decision to Cease Resuscitation 120 prehospital patients in nontraumatic cardiac arrest EtCO 2 had 90% sensitivity in predicting ROSC Maximal level of <10mmHg during the first 20 minutes after intubation was never associated with ROSC Source: Canitneau J. P. 1996. End-tidal carbon dioxide during cardiopulmonary resuscitation in humans presenting mostly with asystole, Critical Care Medicine 24: 791-796

44. Decision to Cease Resuscitation 27 out-of-hospital patients in cardiac arrest looked at EtCO 2 at 3 points 1 and 2 minutes post intubation Maximum EtCO 2 during CPR EtCO 2 in ROSC was higher at each point ROSC No ROSC 1 min 23.0 + 7 13.2 + 14.7 P =.0002 2 min 26.8 + 10.8 15.4 + 5.7 P =.0019 Maximum 30.8 + 9.5 22.7 + 8.8 P =.0022 Source: Asplin BR. 1995. Prognostic Value of End-tidal Carbon Dioxide Pressures During Out-of-Hospital Cardiac Arrest, Annals of Emergency Medicine 25 (6): 756-761

45. Decision to Cease Resuscitation 90 victims of prehospital cardiac arrest with PEA ROSC No ROSC Initial 10.9 + 4.9 11.7 + 6.6 P =.672 (NS) 20 min 31.0 + 5.3 3.9 + 2.8 P <=.0001 100% mortality if unable to achieve an EtCO 2 of 10mmHg after 20 minutes Source: Wayne M. A. 1995. Use of End-tidal Carbon Dioxide to Predict Outcome in Prehospital Cardiac Arrest, Annals of Emergency Medicine 25 (6): 762-767

46. Decision to Cease Resuscitation Capnography provides another objective data point in making a difficult decision 0 2 5

47. Optimize Ventilation Monitor ventilation efforts and carbon dioxide levels with capnography Carbon dioxide has a profound affect on cerebral blood flow (CBF) Influences intracranial pressure (ICP)

48. Optimize Ventilation Use capnography to titrate EtCO 2 levels in patients sensitive to fluctuations Patients with suspected increased intracranial pressure (ICP) Head trauma Stroke Brain tumors Brain infections

49. Optimize Ventilation Intracranial pressure Tissue and fluid contained within a rigid compartment Affected by changes in any component Treatment goal Maintain stability Avoid raising intracranial pressures

50. Optimize Ventilation Treatment of patients with head injuries and ICP Hyperventilate the patient? Do NOT hyperventilate the patient?

51. Optimize Ventilation Hyperventilation is very effective at lowering ICP Prophylactic hyperventilation once mainstay therapy New guidelines recommend against prophylactic hyperventilation Avoid hypoventilating patients with suspected high ICP Source: Huizenga J.E. 2000. Guidelines for the Management of Severe Head Injury: Are Emergency Physicians Following Them? Academic Emergency Medicine 9 (8): 806-812

52. Optimize Ventilation Treatment goals Maintain stability of EtCO 2 levels Maintain adequate blood flow to the brain Avoid secondary injury as a result of inducing or increasing cerebral edema

53. Optimize Ventilation Treatment goals Avoid cerebral hypoxia Monitor blood oxygen levels with pulse oximetry Maintain adequate CBF

54. Optimize Ventilation High CO 2 levels induce cerebral vasodilatation Positive: Increases CBP to counter cerebral hypoxia Negative: Increased CBP, increases ICP and may increase brain edema Hypoventilation retains CO 2 which increases levels CO 2

55. Optimize Ventilation Low CO 2 levels lead to cerebral vasoconstriction Positive: EtCO 2 of 25-30mmHG causes a mild cerebral vasoconstriction which may decrease ICP Negative: Decreased ICP but may cause or increase in cerebral hypoxia Hyperventilation decreases CO 2 levels CO 2

56. Optimize Ventilation “In summary, after either cardiac arrest or head trauma, ventilate the comatose patient to achieve normocarbia (Class IIa).” P 168 “Routine hyperventilation may be detrimental and should be avoided (Class III).” P 168 Source: Guidelines 2000 for Cardiovascular Resuscitation and Emergency Cardiovascular Care, C irculation 102 (suppl I) 8. August 22,2000

57. Optimize Ventilation Monitor ventilations with capnography to maintain appropriate and stable CO 2 levels Follow local protocols and medical direction

58. Part 3: The Intubated Patient Summary Capnography can be used in intubated patients for Verification and documentation of ET tube placement Immediate identification of ET tube displacement Confirmation of adequate chest compressions Early indication of ROSC

59. Part 3: The Intubated Patient Summary Capnography can be used in intubated patients to Detect cardiac output when no pulse palpable Help in the decision to cease resuscitation Maintain CO 2 levels in patients sensitive to changes

60. Part 3: The Intubated Patient Now you’re catching on!